Termination of Services Report
Client Name:
Date of Birth:
EPI Clinician:
EPI Psychiatrist:
Date File Opened:
Mental Health Centre:
Date of Termination of Services:
GP Name and Contact Information:
Reason for Termination of Services:
Moved
Declined services
Requires longer-term services In remission/recovered
Referred to:
ACSS/ACM
CRP
Community agency Other -
ASTAT
Addictions services
Transferred within EPI
Requires other services
General physician
Child and Youth Mental Health
Other EPI Clinician -
Deceased
Other -
Private psychiatrist
No follow up
Current psychiatric medication
Name
Dose
Treatment Adherence
Details
Medication
Adherence to recommended
medication
Other components of care
General adherence to
recommended components of care
(i.e., appointments, groups, etc.)
Select
Select
1
Details
Psychotic Symptoms
Are positive psychotic symptoms
present?
Select
IF YES
Was clozapine offered? Select
CBT for psychosis provided? Select
Other Significant Symptoms
Are other symptoms present
Select
(negative symptoms, mood, anxiety, etc.)
that merit treatment?
Substance Use
Note changes in substance use
Select
Housing
Current living situation
Select -
Is housing appropriate and safe?
Income
Main source of income
Select
Income is adequate to support
current living situation?
Psychosocial Functioning
Current difficulties with functioning?
Select
Select -
Work and School
Current paid employment or
schooling?
Volunteer work?
Hospitalization
While in EPI, how many times was
the client in hospital for psychiatric
reasons?
Follow-up
Do you believe the client is ready for
discharge with minimal or no mental
health treatment follow-up?
Select
Select
Select
Select
Select
HoNOS
Adult version 1:
Adolescent version
2:
1:
13:
3:
4:
2:
3:
sub-total (1-13):
5:
4:
6:
5:
7:
6:
14:
8:
7:
15:
9:
10:
8:
9:
Total (1-15):
11:
10:
12:
11:
Total:
12:
Diagnosis
Axis I
Axis II
Axis III
Axis IV
Axis V (GAF)
Rule-out diagnoses
Client Satisfaction Questionnaire mailed? Select
Family Satisfaction Questionnaire mailed? Select
Termination report faxed to GP?
Select
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2